Pulmonary and Medicine Associates
27472 Schoenherr Rd, Suite 100, Warren MI 48088
Phone
: 586-751-8844
WORKER'S COMP ACCIDENT INSURANCE QUESTIONARE
Must be completely filled out in order to process claims
Patients Name
*
Address
*
Phone Number
*
Date of Accident
*
Claim Number
*
Description of Injury
*
Insurance Carrier
*
Claim Submission Address
*
Employer
*
I authorize the release of any medical information necessary to process this claim.
I permit a copy of this authorization to be used in place of the original.
I hereby authorize Pulmonary and Medicine Associates, PLLC to submit claims on my behalf for services rendered.
I authorize that those payments from my insurance company be made directly to Pulmonary and Medicine Associates, PLLC.
I certify that the information I have provided is correct
Date
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Signature
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